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� � io � <br /> , City of Orono v ti� 70�0. �� <br /> � � <br /> Building Permit Application for Internal Work <br /> (windows, doors, siding, re-roof, etc.) <br /> Mailing Address: Permit number: a�d/0-D/�100 <br /> O�v�,�.0 PO Box 66 <br /> Crystal Bay, MN 55323-0066 Date received: ��-SD-�� <br /> � <br /> � ��`���,��;` �, Street Address: Received by: <br /> < „�- ti <br /> �,nt� �����,��ti 2750 Kelley Parkway Plan review fee: y3. � <br /> kESH�4 Orono, MN 55356 <br /> �_—� a���-�i�59 <br /> � Total Fee: <br /> Main: 952-249-4600 Fax: 952-249-4616 www.ci.orono.mn.us <br /> This application form must be completed in tull and all required information must be submitted. <br /> Incomplete applications will be returned. (Please print) <br /> GENERAL INFORMATION: ,(� �1 � <br /> Job Site Address: � �'�C: C, ��r-� �L�C1� CL("' C--�C`12�, /f�� �.��5�( <br /> Will this be a Parade of Homes, Remodelers Showcase Home or other Display Home? ❑ Yes [�lo <br /> /f yes, a special event permit is required with Police Department and City Council approval 60 days prior to the event. Shuttle bus service wi/l be <br /> required unless applrcant demonstrates sufficient on-site parking is available. Non-permitted events will not be allowed. <br /> CONTRACTOR/APPLICANT INFOR-7p-n-ATION: � <br /> Name: .�rti�rC � L"' C Kn c=l.%� <br /> State License# Expiration Date: <br /> Phone: (office) (cell) <br /> Mailing Address: Cit : ZIP: <br /> Contact Person: Applicant is: Contractor / Ho @OW�Af� Circle One) <br /> Email and/or Fax: <br /> PROPERTY OWNER INFORMA ION: � <br /> Name: �� � 1 , <br /> Phone (day): , � � � � <br /> Address —" _ Cit : (%/�, .2–, ZIP: � .`.'�, <br /> Email and/or Fax _��� �,��-p � �e�������i�r t C-� <br /> PROJECT INFORMATION: <br /> Type of Project: Any earth movement may require <br /> MCWD review&permits <br /> �Door(s) �Remodel ❑Water Damage <br /> Minnehaha Creek Watershed District(MCWD) <br /> �Window(s) ❑ Repair ❑ Storm Damage 18202 Minnetonka Blvd <br /> Deephaven, MN 55391 <br /> ❑ Siding ❑ Restoration ❑ Other: (specify) Phone: 952-471-0590 <br /> Fax: 952-471-0682 <br /> ❑ Re-roof ❑ Fire Damage www.minnehahacreek.orp <br /> Overall Project Description: <br /> Estimated Construction Valuation of Project(excluding land) $ t��� , � ��` <br /> .� � <br /> APPLICANT ACKNOWLEDGEMENT: <br /> • Agrees to provide all information required or requested by the Building Department; <br /> • Certifies that the information supplied is true and correct to the best of his/her knowledge. The applicant recognizes that they <br /> are solely responsible for submitting a complete application being aware that upon failure to do so, the staff has no alternative <br /> but to reject it until it is complete; <br /> • Some or all of the information that you are asked to provide on this application is classified by State law as either private or <br /> confidential. Private data is information which generally cannot be given to the public but can be given to the subject of the <br /> data. Confidential data is information which generally cannot be given to either the public or the subject of the data. Our <br /> purpose and intended use of this�nformation is to annually update our records and records of other governmental agencies <br /> re uired b law. If ou re o�su I the iri#prmation, the a lication ma not be issued. <br /> - � <br /> ApplicanYs Signature: ' Date: �� � /O <br /> , <br /> Last Updated: 05-04-2009 <br />